Surgical Ward

During this week’s prac I was working on the surgical ward, which gave a great opportunity to treat patients after cardiac and various abdominal surgeries. Just want to express how much I have enjoyed working in the surgical ward. I sow a guy day one post cardiac surgery and followed the rehab protocol until he got discharged. It’s amazing that day one post operation we sit them over the edge of the bed and walk them in afternoon.

My supervisor let me to do the whole assessment and treatment on this patient (of course she was present at the time). Anyway was really daunting to begin with as this guy had attachments everywhere.

I took a big breath and started my subjective assessment following an objective assessment and so on. In went really very well, I was really pleased that I remembered all the things we have been taught at uni in terms of how to safely mobilise and treat surgical patients.

It was such a good practice in terms of problem list and also to have a real visual picture what the patients look like day one post operation. I am glad to have this experience, as it wasn’t planned. Now I feel that I am ready to do my cardio PCR.

An interesting neural round at RPH

I wanted to share with you a very positive grand neural round experience. A 30 year old patient had a stroke secondary to violent dancing (and possibly connected with ½ an estacy pill). The exact cause of the stroke was not definite. The distribution of the stroke was vertebral basilar, first affecting the vertebral artery and moving rostrally to the basilar. Thus, her symptoms were initially Wallenberg syndrome (AKA lateral medullary syndrome) developed into locked-in syndrome (medial pontine syndrome). Personally, this is most scary condition I have ever heard of. Suffers are conscious and aware of their surroundings but can only respond by eye movement or blinking. The corticofugal, corticospinal and other extrapyramidal systems have been infracted. Their only response to the outside world is the cold binary language of affirmative or negative. The good news is that she started to slowly recover. It has been roughly 9 months post stroke and she is responding well to physiotherapy. Currently, she is able to transfer with 1X assist, and is mobile on an electric wheelchair. Our supervisor believes she will be able to walk independently one day. The patient attended the round and gave a stirring thank you speech. It was one of those moments I thought it was great to be a physio because we can make vast differences in people’s lives. The ability to have positive effects on others is inspiring. On a slightly negative note, the patient’s speech was cut short because she took too long to do it. One other person (surgeon I presume) made the comment to the presenting registrar that he was ‘speaking to those already converted and believed in rehab, and that promotion material was unnecessary and redundant. He believed time was better spent discussing the challenges of rehab. I was initially surprised and even somewhat disappointed with the comment. But after some thought, I felt there was much truth to what he spoke and that a grand round was perhaps not the best forum for ‘promotion’ of rehabilitation.

Laid back

I thought I’d reflect on a colleague that seems to be very laid back but is not in some respects.
One of the supervisors I have been on placement at would regularly arrive at the workplace a few minutes late and usually it would be 10 to 15 minutes before actually being ready for work. I have no problem with that…what I find rather surprising though is the same person having a go at one of my peers when she came back from her lunch 4 minutes late.
I know that being punctual is a sign of respect towards our patients and is an important issue. What I find a bit frustrating is that there seems to be a double standard…it seems to be ok for some people to be late, but not for others.
Anyway, thought I’d share this experience with you and see what you guys think.
Edith

'The Other Side of the System'

Hi All....

I've had an interesting week this week.....being a family member of someone on a major teaching hospital in Brisbane. My brother had the unfortunate event of being hit by a car late Monday night.....and apart from a open, communited distal femur fracture - is fine.

I have had the frustrating experience of trying to get information from the medical staff looking after him. I decided to phone the hospital on Wednesday as he had surgery on Tuesday regarding his fracture etc etc. SO I got the nurse who was supposedly looking after him.....I told her that I was in Perth, nearly graduated physio etc etc and that I did not have a very clear picture from my parents. Turns out the nurse didn't either - she told me he had an ORIF on his R hip the day before (it's L distal femur) and when I said I'd heard distal femur...she said 'yeah, ORIF'd femur - very informative.....I asked her if she was aware of the plan for treatment as my parents had said it was to be a series of surgeries.....she was very honest and said 'nuh'. I then asked her if she could put me through/give me information as to who were the doctors looking after him.....to which she didn't know if he was under the 'trauma' team or the 'orthopaedic' team....again - very helpful.

I can not tell you how frustrated I was when I got off the phone to this lady...and how hard it was to convince myself that Dylan's getting decent care in Brisbane....even though I've worked on the ward of the 'Perth equivalent' and know that ppl do get good care. It is so upsetting to even myself and as a health professional I suppose I didn't really realise how upset I'd be if something traumatic happened to one of my family......so I have a little more empathy (and time) for family members of patients now!

Anyway, I will call again and hopefully find out some more information!

Madeleine

Treating Referrals

I have had a couple of patients this week that have presented via referral for a specific condition. However upon arrival, they describe an entirely different picture. One patient in particular comes to mind in that she was referred due to Achilles tendinosis but on presentation she stated that it was in fact her shoulder which was her main problem, not her ankle. I asked my supervisor what I should assess since her main complaint was her shoulder pain and not her ankle pain. My supervisor explained to me (and to the patient) that we can only legally treat what we have been referred, otherwise this patient would need to come in a second time (privately) and pay for her shoulder to be assessed.

I found this to be a bit of a ethical struggle as the patient presented with her primary pain as something other than her referral and yet we can only treat the referral (leaving her to her own devices for her shoulder pain as she is a pensioner and unable to pay for private physiotherapy services). I’m a little dismayed at the same time as to why the doctor how wrote the referral would not have also referred for the shoulder pain she is complaining of? I can’t imagine her not mentioning it to him as it was the first thing out of her mouth during her subjective exam. I guess as physios we always aim to resolve the patient’s presenting problem, but in the situation where you are not legally allowed to do so, it can become a very frustrating and disappointing experience.

mental health

Hey all,
Reflecting on this week it seems my musculo placement is turning more into a psychiatric practical, something that indeed I feel a little unprepared for. I’ve had 3 patients, just this week, burst into tears during their subjective history. Listening to some of their stories makes the exercise prescription and treatment I am providing seem slightly insignificant in the big scheme of things. I know that the chat I have with them is far more beneficial than any hands on therapy I provide.
Many of these patients have been in the “system” for years, with out clear diagnoses and it seems that they end up at ‘out patient physio’ once doctors can’t figure out what is wrong or how to help them. I have heard countless times that they have been told there is nothing wrong with you. I can only imagine how frustrating this must be for them.
My question to you is how can we help these patients, who clearly do need physio, when they have such major psycho social issues that traditional physiotherapy will be ineffective if we are unable to provide some psychological intervention/support during treatment. And if this is required of us, then why are we not taught strategies to deal with and understand such conditions/disorders at uni???
Do not say refer to social worker/pyscholgist/psychiatrist as this is not going to help me half way through my assessment when a patient has a massive panic attack and is screaming in a fetal position on the floor (which actually happened today!!). Obviously it is unethical to refuse to see a patient until their mental health is under control…
Jess

Perhaps to the dismay of some, I will bring up the topic of Bobath techniques again. Nonetheless, the subject of my reflection is not exactly Bobath itself. I am merely using it as an example. I apologise if it appears I am beating about the bush.

I was searching the literature on the efficacy of Bobath techniques (AKA neurodevelopmental technique) and discovered that there is limited support for its use. A couple recent systematic reviews found nil evidence to support (or refute for that matter) its clinical value. One randomized trial found Bobath to be just as effective as motor learning based neural rehab (I think Carr and Sheppard methods), and another RCT found Bobath to be less effective. My search was by no means exhaustive. I simply typed in ‘Bobath’ under 'search' on the Pedro website. As I have mentioned in my last Blog, my neural placement is heavily Bobath based.

If Bobath is not the gold standard, why is it used as gospel? The issue that I’d like to discuss is how much of our hospital clinical experience is dogma, perpetuated by very experienced practitioners who have specialized in one philosophy of treatment? The use of the word dogma is likely too strong, but I am just trying to illustrate a point. If the clinical experience is based on one school of thought, my concern is that it prevents integration of other possibly effective neural rehabilitation techniques. Maybe the gold standard of neural patient treatment is a combination of motor learning and Bobath methods. However, if we are taught to believe one particular method of treatment is the best, where is the incentive to research new methods or a combination of methods?

I used Bobath as the example, but I think it can be with anything we are taught. It makes me appreciate Anne teaching us an integrated approach. Just a thought!